Pre-Hospital ECG Interpretation

Greg Cuculino

When to do it
Chest pain - Duh! Abdominal pain
>55 y/o Hx of DM,CAD,HTN, or increased cholesterol

Shortness of Breath(CHF)

What to look for

Rate Rhythm ST segment changes
Elevations or depressions

Rate
This one is easy Too fast or too slow Remember treatment is based not on the number but the clinical scenario A heart rate of 40 is fine if the BP and mental status is good

Rhythm
Normal sinus rhythm
A p wave for every QRS and a QRS for every p

1 degree heart block

PR interval longer than 0.2 No big deal

Second Degree HB Type1 (Wenckebach)

Progressive lengthening of the pr interval and then a dropped beat Grouped beats

Second Degree Heart Block Type 2(Mobitz II)

Constant pr interval but then dropped beat

Third Degree heart Block

This one is an issue No correlation between the p wave and the QRS Can have junctional or ventricular escape beats NO LIDOCAINE!!!!!

Quiz time

SVT

Narrow complex tachycardia Regular Usually no p waves

Afib

You guys know this one No organized p wave activity Irregularly irregular

Aflutter

Saw-tooth pattern Usually around 150 Regular Treat like afib

Vfib

This one sucks Shouldnt catch this one on ECG

Vtach

Wide complex tachycardia No p waves Treat based on symptoms

Torsades

Some magnesium please

ST segment changes

Measure from the TP segment Depression is ischemia Elevation is infarction

How much is enough?

At least 1 mm (one little box) in 2 anatomically contiguous leads
Across the precordial leads :V1-V6 II,III,aVF I,aVL

Location, location, location

I,AVL,V5,V6 - LATERAL V1-V2 - SEPTAL V3-V4 - ANTERIOR V5-V6 - LATERAL II,III, AVF - INFERIOR IT DOESNT REALLY MATTER
Except that inferior MIs are more dependent on volume status Can quickly drop BP with NTG if the patient is dehydrated

Reciprocal Changes
Areas opposite the heart will experience ST depressions when the other side is experiencing elevations Common to see ischemia opposite infarction Not necessary but helps confirm the diagnosis Inferior is opposite anterior and lateral

Reciprocal Changes

Bundle Branch Blocks

The Rabbit ears
V1-V2 is a RBBB V5-V6 is a LBBB

QRS is>120 ms (3 little blocks) Will change the ST segments

RBBB

LBBB

LBBB with an AMI

CONCORDANT ST segment changes
Usually if QRS is up, ST segment is down If QRS and ST segments are in the same direction, think MI

ST segment elevations > 5mm Always a tough distinction

Ant MI

Inferior MI

Posterior MI
ST depressions and a tall R wave in V2 (flip the ECG) Associated with inferior MIs

Other things to notice

ECG findings that are not infarctions, but will make you look good (and possibly save a life)

Hyperkalemia
Like pulling on the T wave Peaked t waves Then first degree block The lose p waves and QRS widens
Sine wave

Hyperkalemia again..

Hyperacute Ts
When you see really big T waves, think of 2 things
Potassium (increased) and preinfarction

Pericarditis
Diffuse ST segment elevations and PR segment depression No reciprocal changes

Quiz time

ECGs

First Degree

Wenckebach

Mobitz

Third Degree (please dont give )

SVT

Afib

Aflutter

V Tach

VFib

Torsades

LBBB

RBBB

Hyperkalemia

Hyperkalemia

Hyperacture Ts

Ant MI

Ant MI

Post MI

Inferior MI

Pericarditis